treatment outcomes perez
DESCRIPTION
TRANSCRIPT
“Stephen, I’m taking my meds, I swear”
Adherence as a Path to Virologic Suppression
Stephen Perez, RN, NP, AAHIV-SHealthHIV
• Define adherence as it relates to antiretroviral therapy
• Discuss current positive and negative predictors of adherence
• Describe methods for improving adherence
• Identify effective strategies for increasing patient adherence in the clinical setting
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Objectives
• How do we define adherence?– Taking medications or treatments as
prescribed or advised by a health care provider
– Average ART adherence rate in the United States is approx. 70%.1
– Earlier studies of adherence showed resistance associated with <95% adherence.2
– Providers assessments are often inaccurate! 1,2
– There is no gold standard for assessment33
Adherence
• Reduced Rates of Resistance
• Improved Quality of Life
• Improved Virologic Suppression
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Why does adherence matter?
U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012.
• Positive Predictors– Ability to identify medications – Ability to describe the proper dosing– Lower pill burden– Ummmmmmm…………
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Predicting Adherence
1. Matchinger, E & Bangsberg, D. 2006. Adherence to Antiretroviral Therapy. UCSF HIV inSite. http://hivinsite.ucsf.edu/insite?page=kb-03-02-09 accessed April 3, 2012.
• Factors Associated with Non-Adherence– Younger age– Age-related changes–Mental health/Social issues– Non-disclosure of HIV status– Active substance abuse– Side Effects– Complex regimens– Non-adherence to clinic appointments
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Predicting Aherence
U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012.
• No gold standard• Keep it simple and non-judgemental• Normalize less than perfect adherence• Try to minimize “socially desirable”
responses• Survey about a finite time: “last 3 days”,
“Last week”• Ask about missing other meds or treatments• Pill boxes, bottle cap counters, dispensing
systems, biological markers
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Assessment of Adherence
U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012.
• Do you manage your own medications? If not, who manages them for you?
• What HIV medications do you take and what is their dosage? When do you take these?
• What is your average daily schedule like? How well does taking your HIV medications at this time fit into your daily schedule?
• How do you remember to take your medications?• How many doses of your HIV medication have you missed in
the past 72 hours, past week, past 2 weeks, and past month?• When are you most likely to miss doses?• Do you have any adverse effects from your HIV medications?
If so, what are they?• Are you comfortable taking medications in front of others?• What is most difficult about taking your medications?• How do you like working with your pharmacy?8
Questions to Assess Adherence
1. Health Resources and Services Administration, HIV/AIDS Bureau, 2011. Guide for HIV/AIDS Clinical Care. “Adherence”. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-406_adherence.html accessed
April 3, 2012
• Assessment of the patients readiness for ARV’s• Use critical thinking when prescribing ARV
therapy• Simplify a patients regimen• Educate around side effects and adverse drug
reactions– Let the patient know they are supported
• Talk about the risks/benefits of therapy• Identify barriers they may not have considered • Get creative!
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Interventions to Improve Adherence
• Patient-centered approach• Educate your patients• Assess for use/need for specific
interventions (medisets, pill boxes, text reminders)
• Multi-disciplinary approach if/where available
• Expect the unexpected• Hang in there
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Strategies for Improving Adherence
• Ms. D– 44 y.o. HIV positive African American
female – HIV-positive for 9 years– Presenting for first HIV care visit in 3
years• No meds, can’t remember her last meds• Feels sick. CC: “Has sore on her stomach”• BP is 86/54, Pulse is 130, Temp: 101.4 • Intake labs, were CD4 32, VL 132,000• Actively drinking 6-10 beers a day, using
crack cocaine off and on weekly 11
Case Study in Adherence
• Ms. D– Physical exam:
• In addition to the vitals noted, she has a large open abscess and cellulitis on her abdomen, abscesses on her upper thigh/buttocks, palpable femoral nodes.
• Height is 5’3”, wt. 86 lbs • ED referral, and admission for 4 days, discharged on TMP-SMX
and azithromycin
– She returns 4 months later• Wt. has remained the same, no meds, t 98/60, p110, afebrile.• Substance use pattern is the same• Is indifferent about meds, and indifferent about care in
general • Hx: has been on meds before (can’t name them) records say
Lopinavir/ritonavir and emtricitabine/tenofovir DF (She says they “tore up her stomach”)
• Previous records say that she has M184v but was <75. • Sexually active, inconsistent condom use• Uninsured
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Case Study in Adherence
• Ms. D– Daughter won’t speak to her because of
her substance use– Recently was arrested for “something”,
Has court case pending–Wants to get sober before the hearing
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Case Study in Adherence
• Plan for Ms. D– Prescribe her darunavir/ritonavir and
emtricitabine/tenofovir DF (once daily). – Recheck labs for baselines (CD4 75, VL 89,000)– Enroll her for one visit with SAC, RNCM, and SW– Bactrim daily for PCP prophylaxis until meds arrive– Preemptively give her OTC for diarrhea and RX for
nausea meds – Work out a visit schedule and assist her with
transportation arrangements – Agree to write a letter of support for her court case – I made her a deal
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Case Study in Adherence
• Plan for Ms. D (continued)– Adherence education and counseling
session with RNCM and subsequent monthly meetings
– Counseling about diet– Sees provider every 2-3 months– SAC and SW every 2 weeks– Took a year before she came back
undetectable, misses about 1-2 doses a month
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Case Study in Aherence
• Today Ms. D is still undetectable• She weighs 130lbs • Still struggling with ETOH sobriety,
stopped crack altogether• Avoided jail time• Was maid-of-honor at her daughter’s
wedding • Brought in pictures of her 4th
grandchild the following Christmas 16
Adherence
• Virologic suppression begins with adherence.
• Ultimately its up to the patient, but providers play a crucial role
• Be creative• Be determined • Be realistic
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Adherence Take Home
1. Matchinger, E & Bangsberg, D. 2006. Adherence to Antiretroviral Therapy. UCSF HIV inSite. http://hivinsite.ucsf.edu/insite?page=kb-03-02-09 accessed April 3, 2012.
2. Health Resources and Services Administration, HIV/AIDS Bureau, 2011. Guide for HIV/AIDS Clinical Care. “Adherence”. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-406_adherence.html accessed April 3, 2012
3. U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012.
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References
QUESTIONS?
www.NCHCMC.org202-232-6749
HealthHIVAETC NCHCMC
2000 S Street NWWashington, DC 20009